Adult Psychological Assessment Cases

Case 4

Case Summary

The client was a 32 years old man who had achieved his education up to MBA, was serving as a police officer and belonged to middle socioeconomic family. He came to the Centre for Clinical Psychology with the complaints of shyness, confusion in social situations, inability to talk adequately in front of people on a higher pedestal, sweating, blushing of face, fear of embarrassment, anticipation of negative evaluation, avoidance of social interactions and disturbance in social life. He was informally assessed through a clinical and diagnostic interview, mental status examination, visual analogue, dysfunctional thought record while the Liebowitz Social Anxiety Scale was implemented as formal assessment. After thorough examination, the client was diagnosed with Social Anxiety Disorder. He was treated on the lines of Cognitive Behavior Therapy through the techniques of cognitive restricting, socialization, cost-benefit analysis, assertiveness training etc. The pre and post assessment of the client showed a significant decline in the client’s complaints and symptoms showing efficacy of the therapy.

Bio Data

Name: S.T.

Age: 32 years

Gender: Male

Education: MBA

Occupation: Police Officer

No. of Siblings: 3 (1 sister, 2 brothers)

Birth order: First born

Marital Status: Single

Religion: Islam

Informant: Client Himself

Reason and Source of Referral

The client came to the Centre for Clinical Psychology with the complaints of shyness, confusion in social situations, inability to talk adequately in front of people on a higher pedestal, sweating, blushing of face, fear of embarrassment, anticipation of negative evaluation, avoidance of social interactions and disturbance in social life. The client was referred to a trainee clinical psychologist for the assessment and management of his symptoms.

Presenting Complaints

Table1: Presenting Complaints of the Client

Duration	Complaints
From 2-3 years	I am ashamed to go in crowd. If anyone is near me than i cant think properly
From 2-3 years	I get confused very quickly. Can’t even talk. Can’t even give the correct answer
From 2-3 years	Where I think there are people older than me, I can’t perform properly
From 2-3 years	In any such situation I start sweating. The face turns red
From 2-3 years	Where people are present, despite the preparation, it seems that I will do something wrong, or something will come wrong out of my mouth
From 2-3 years	Every time i worry about what people will think
From 2-3 years	I often refuse to go to places where people will be. I like to stay in the room on such occasions.

History of Present Illness

The client’s problems date back to his childhood when he was studying in school for primary education. He was in 5^th grade when he had to go through a rough phase of life and did not have adequate support to go through the phase. During his time in 5^th grade, he was bullied by his seniors multiple times. The client was a naturally shy person and the senior boys of the school took advantage of him. They usually came to him in the recess time and asked him to do favors such as serving them lunch, bringing them food from the canteen, making their practical copies or fetching books from the library. In addition they would confiscate his lunch, geometry and books and also tore down his copies. This happened almost daily which made the client skip school but he was unable to tell his parents about it. He had the perception that his parents will get angry upon him for making excuses and telling lies. His grades declined due to the stress and his relationships with the teachers also declined. His teachers perceived him as a below average student who was not interested in studies and was not confident. The client started to remain in his class during recess and when the teachers noticed his behavior they thought that it was due to his shyness. They held parent teacher meetings to discuss the client’s problems but all of them thought that the grades were low as the client was not interested in studies and school. The client did not share his problems with his siblings or parents neither did he make friends at school. The 5^th grade passed in the same circumstances after which his parents decided to change his school so that the grades may improve.

The next school proved to be better for the client but he was still afraid of the elder boys. The school had better management and kept discipline during the school timing. This made the client focus on his studies more than the issue of people teasing him or bullying him. His grades improved and he made friends in the new place. His teachers started to hold a positive view about him. His performance in sports improved but he never took the initiative to speak in class by himself or taking part in extra-curricular activities. He remained a shy student but academically improved to a greater degree. His studies after that went on without any hurdles. He passed his matriculation and intermediate with above average grades. During his bachelors and masters as well he performed satisfactorily but still remained shy while talking to others especially girls.

After he achieved his postgraduate education, he decided to go into the Police force. He was motivated by his childhood experiences and wanted to stand against bullying. He wanted to overcome his shyness and perform better so applied in the forces and got accepted for the program. Throughout the training program and his 2 years of service he did not face any problem regarding his social behavior. In 2016, he faced another psychological stressor which triggered his current symptoms. He was given a task by his seniors to prepare a presentation which had to be given in front of his superiors and foreign officials. He tried to decline the offer but he was insisted on doing so. The presentation had to be given after a month of the proposal and that month was the most stressful for the client. He consulted each of his colleagues for help and guidance. He prepared the presentation investing all his energy to do a commendable job and practiced innumerably in front of his friends and colleagues. On the day of presentation, he felt extremely anxious and fearful. The client started to give the presentation but felt dizzy and within 5 minutes of presenting, he felt an increase in his heartbeat and excessive sweating. He had to reach for water repeatedly as he felt dizzy but completed the presentation adequately. There was applause round the hall and he was given positive feedback upon his performance. After the presentation, he reported to his immediate senior who gave feedback on his performance. He was told that he was appearing nervous, his voice was shaky, face was flushed red and he was sweating a lot. Along with these comments, positive compliments were also given. The following night, client could not sleep as he kept on pondering upon the comments of his boss.

After the incident, there were frequent episodes of anxiousness, sweating and inability to talk when the client had to talk in his friend’s circle or in professional meetings. He started to assume that his face and ears were getting red and he would feel embarrassed. Whenever the symptoms appeared, he left the situation or meeting. This compromised his performance chart because of which he considered to seek treatment for his issues. He consulted his friends for reassurance and opinion to get better. One of his friends recommended him to see a psychiatrist or a psychologist. He then came to the Centre for Clinical Psychology with his complaints for the management of his symptoms.

He did not report any physical or sexual abuse. He was taking any medications at the moment neither was there a history of accident, injury or organic disease.

Background History

Family History

Father. The client’s father was a 65 years old, uneducated business man. He has his own fields in a village where he use to grow crops along with his brother. He was diagnosed with blood pressure for which he took medications. He was a clam natured person who got angry rarely. He rarely expressed his anger and also kept quiet mostly. He was a highly religious person. His relationships with his siblings, wife and children were satisfactory. The client’s relationship with his father was also respectful and caring but due to the client’s shyness he still felt some degree of fear from his father. They occasionally sat down to discuss business matters but the meetings gradually reduced when the client had to move away after his joining in the police force. They still talked over the phone and cared about each other. The client’s childhood experience of bullying was not shared by his father as he thought that his complaints would be misperceived. Other than that, the client was able to discuss most of his issues with his father.

Mother. The client’s mother was in her fifties, educated up to intermediate and was a housewife. The client described her as a shy, calm and down-to-earth person who was always ready to help others. She had no physical or psychological problems. She was also religious and tried to make her children turn towards religion as well. Her relationship with the client was loving and caring. She dedicated her life for the upbringing of her children and always remained concerned about their well-being. The client usually called her mother and shared his problems with her after he entered adulthood.

The client’s parents had a satisfactory relationship betweem them. They had been married for 34 years but the interaction decreased in the last 10 years. Both remained indulged in their work and were satisfied by each other.

First born was client himself.

Second born brother. The client’s brother was 28 years old currently doing his masters from a reputable university. He was an outgoing, social and cheerful person. He was confident according to the report of the client. The client and his brother had a distant relationship as he always had to behave like the bigger brother. He did not feel interested in his brother’s activities and had to act like a grown up in the house as well. Both the brothers still cared and helped each other in the time of need.

Third born brother. The younger brother of the client was 22 years old and was doing his bachelors in Computer Science. He was an intelligent and above average student. The client’s brothers had mutual understanding and harmony between them but the client himself did not have close bonding with both the brothers. His younger brother also did not get frank with the client out of respect and obedience. The client was treated as a father figure. The client tried to keep his necessities fulfilled and would give him gifts whenever he visited home.

Last born sister. The client’s youngest sibling was his sister who was 20 years old and was studying in a nearby college. She was the most pampered child being the youngest and only sister. The client had immense love for her sister. Although their relationship was also not close as the client lived away but still they had respect and care between them. The client wished all the good for her sister.

General Home Atmosphere. The client belonged to a middle socio-economic family. His household environment was always calm and nourishing. There were seldom fights or screaming. The children were asked to live harmoniously. The authority figure of the house was the client’s father but discussed issues with his wife. The family was moderately social. They visited their relatives house frequently and also treated their guests well.

Personal History

Birth and Childhood History. The client was born after a complete gestation period of 9 months through a C-section. His vaccinations were properly done and developmental milestones were achieved at appropriate age. The client did not remember much of his early childhood neither had a discussion on this topic with his parents. He reported that he had a neurotic trait of rubbing his fingers whenever he was nervous. He used to rub his nails on his fingers pressing them deeply into the skin. The habit automatically vanished when he entered adolescence.

Educational History. The client started his education at the age of 6 years. He was put in a local school as his father believed that children can excel on their own as well. Until the fourth class the client remained an average and obedient student. In 5^th class, he had to face bullying by the senior boys in school who used the client for various purposes. The client was never physically hit or sexually assaulted but the frequent threats of the seniors kept him scared. The client started to remain in his classrooms and in front of his teachers. His teachers became dissatisfied with his performance and informed his parents about low grades. None of the parents or teachers knew about the bullying neither were they told by the client. After the below average result in 5^th grade, the client’s school was changed and he got rid of the bullies. From 6^th grade onwards, client performance improved but he still remained a shy student he was good in sports but did not take active participation in any of the extra-curricular activities. He continued his education up to masters with satisfactory percentage. He did not have to face any other psychological stressor throughout his academic career, rather maintained healthy relationship with his teachers, colleagues and fellow students. He remained satisfied with his educational life and considered the bullying episode as a learning opportunity.

Pubertal and Sexual History. The client achieved puberty at the age of 4 years when started to notice changes in his genitals, face structure and voice. He did not face any emotional disturbances at that time. The client sometimes watched erotic movies after he hit his puberty but he did not have any history of homosexual or heterosexual experiences. He also did not report any incidence of sexual abuse or harassment.

Occupational History. The client joined the police force after his postgraduate education. Despite being a shy person, he was able to get in, in the job. He had admirable performance at his job in the initial two years. He maintained satisfactory relationship with his seniors. In the 3rd year of his service, the client had to face a stressful situation when he had to give a presentation in front of a hall of senior officers and foreign officials. The client felt extremely nervous and anxious before giving the presentation. Even after the performance, he was given both positive and negative comments but he kept on focusing on the negative ones and thus became more conscious of his actions. After the event, his performance declined slightly as he started to avoid big gatherings or situations in which he may become the focus of attention. On the other hand, the client’s relationship with his colleagues was satisfactory and he presented himself to all friends in the time of need. He also shared his symptoms and problems with two of his close friends who recommended him to seek psychological advice.

Pre-morbid Personality. The client had a shy personality since childhood but he used to remain calm and relaxed while meeting people. He would give answers with adequate speech quality. He was not reluctant in going to gatherings rather encouraged his friends to go out as well. Moreover, he did not use to worry excessively about his appearance or performance. He remained composed in front of his seniors and performed his job well. His frustration tolerance was high and remained steadfast in his work. He had more interactions with his friends, colleagues and relatives before the symptoms started to occur.

Psychological Assessment

Informal Assessment

Informal assessment was conducted on the following lines

Clinical Interview
Mental Status Examination
Visual Analogue
Dysfunctional Thought Record

Clinical Interview

Informed consent was obtained from the client to ensure he was permitting therapy. A clinical interview was held with the client to assess the symptoms and its intensity, duration, settings and frequency. Moreover, the interview helped in eliciting history regarding the client’s presenting complaints, reasons for development, triggering factors and the factors through which the symptoms were being maintained. It also aided in finding the etiological factors and assessing the line of treatment for the client.

Mental Status Examination

The client was a tall heighted man having a muscular built and appearing to be in his thirties. He was wearing neat and tidy clothes and his hygiene was maintained. He sat on the chair with a straight posture and his actions were greatly pronounced. He kept on moving his leg. He maintained less eye contact while talking but kept his hands clenched tightly. His mood and affect were congruent. He appeared to have a pleasant mood at the time of the interview but he reported that he remained irritable mostly. He was attentive towards the therapist and maintained concentration throughout the sessions. His tone of speech was high and rate of speech was fast. His abstract thinking and judgment was also adequately present. He had a fair insight regarding his problems.

Visual Analogue

The client was asked to rate his problems on a scale of 0 to 10 in order to know her perspective on the degree of problems caused by the symptoms and her priority of dealing with symptoms. He was explained that 0 meant that the problem was least problematic while 10 meant the problem was most problematic. This helped in creating a symptom specific management plan based on the severity and priority of each symptom.

Table 2: Symptoms and their severity according to the client

Symptoms	Severity (0-10)
Feeling of embarrassment while going in front of people	9
Fear of scrutiny, evaluated or being ashamed	9
Fear of performing inadequately	9
Becoming confused in front of others	9
Avoiding presentation or social activities	8
Sweating, flushing of face	8

Dysfunctional Thought Record

The client was given a dysfunctional thought record to take into account the cognitive component of his problems. It aided in later conceptualizing the symptoms to him.

Quantitative Analysis

Table 3: Areas of the DTR and the client’s responses

Frequency of Thoughts	1-2 times per day
Intensity of Emotions	9 on average
Intensity of Physiological responses	9 on average

Qualitative Analysis

Table 4: Areas of the DTR and the client’s responses

Settings/Situations	Presence of seniors Presence of friends or colleagues especially females Talking to someone superior Going in areas where there are a number of people
Content of thought	I will not perform adequately People will think I am dumb People will judge me wrongly I will do something stupid People will notice my nervousness, sweating and flushing of face
Emotions	Anxiousness, Irritability
Physiological responses	Heavy sweating, increased heartbeat, confusion, flushing of face
Behavioral/ Cognitive responses	Avoiding parties or situation in which more people are present Leaving settings in which seniors are present Not taking initiatives Avoiding females

Formal Assessment

Formal assessment was carried out through:

Liebowitz Social Anxiety Scale

Liebowitz Social Anxiety Scale

The scale was administered on the client to obtain a detailed analysis of the situations in which he felt anxious and the degree of his anxiety. The scale also tailored to offer the client’s urge to avoid social situations (Liebowitz, 1987). The scale had 24 questions and the client was asked to rate each question on a scale of 0 to 3 for the level of anxiety and degree to which he wanted to avoid those situations.

Quantitative Analysis

Table 5: Area and client’s scores on the Liebowitz Social Anxiety Scale

Area	Client’s scores
Performance Anxiety subscale	53
Social situation subscale	15
Total Score	68 (above cutoff)

Qualitative Analysis

The client’s score correspond to the very probable level of Social Anxiety Disorder. It is above the cut off i.e. 30 which means that the client had a high probability of having Social Anxiety Disorder. It is clear through the results that the client had an excessive fear of performance anxiety while situations such as calling people, expressing disagreement or interaction with unknown people were not problematic for the client. He expressed the most anxiety in situations where he was the center of attention and the gathering was composed og known people. There was high probability of the client to avoid these situations as well.

Summary of Informal and Formal Assessment

The detailed assessment of the client shows that he considers himself unable to interact or perform in social situations and hence tends to avoid them. He experiences distress, anxiety and irritability in these conditions because of which his social and occupational functioning was being compromised.

Diagnosis

(F40.10) 300.23 Social Anxiety Disorder

Differential Diagnoses

Panic Disorder: Panic disorder is diagnosed in an individual when there are recurrent episodes of physiological arousal and his major focus is on the recurrence of the attack. On the contrary, social anxiety disorder is diagnosed when the client has the primary concern of negative evaluation. Moreover, panic attack can be experienced by an individual while he is alone as well but social anxiety disorder is specific to social situation even if it’s the presence of a single person (APA, 2013).

Normative Shyness: Normative shyness is also a trait that is found in many individuals but when it exceeds a certain limit and starts to cause disturbance in social, occupational functioning then it is diagnosed a social anxiety disorder. Moreover the fear of negative evaluation greatly signifies the diagnosis. Due to the presence of concerns regarding scrutiny and evaluation and the disturbance in social and occupational functioning, the client was diagnosed with social anxiety disorder (APA, 2013).

Prognosis

The client had good prognosis as he has fair insight about his issues and was also willing to take the therapy. Moreover, his symptom severity also indicated that they can be controlled and maintained fairly well. His compliance and dedication also increased the prognostic value of therapeutic techniques.

Case Formulation

The present client was a 32 years male presenting with anxiety in social situations, confusion when replying inability to talk in front of people and physiological responses. He was diagnosed with Social Anxiety Disorder according to the Diagnostic Statistical Manual. The developmental psychopathology of social anxiety disorder points out that childhood shyness can lead to future acquisition of Social Anxiety Disorder (SAD). Ollendick and Hirshfeld-Becker (2002) studied the developmental causes of SAD and found that children who are shy are not gven proper guidance to tackle with their shyness later develop extreme anxiety in dealing with people or interacting in social situation. They develop a consistent pattern of anxiousness in their repertoire which can contribute to the enhanced risk of developing SAD. The client’s case can be related to this as he was shy from his childhood. He was reluctant in taking initiatives in school as well so the same pattern was being followed now. Hence, his disorder can be attributed to his prior functioning as a child.

McCabe and his colleagues (2010) studied the relationship of bullying in childhood and the increased probability of developing an anxiety disorder. They found that 92% of the individuals who self-reported bullying indeed developed Social Phobia. They attributed that aversive conditioning experiences, such as severe teasing, have been proposed to play a role in the development of social phobia and that the core feature of social phobia is a fear of social situations in which a person may be embarrassed or humiliated. This conditioning thus associates bullying with the acquisition of SAD. The present client also faced bullying in his school years which was kept hidden from authority figures and not handled appropriately. The assumptions and beliefs formed at that time may have now triggered the disorder in the client presently.

Behaviorists believe that social phobia is a result of a two factor conditioning model. That is, a person could have a negative social experience (directly, through modeling, or through verbal instruction) and become classically conditioned to fear similar situations, which the person then avoids. Through operant conditioning, this avoidance behavior is maintained because it reduces the fear the person experiences. There are few opportunities for the conditioned fear to be extinguished because the person tends to avoid social situations. Even when the person interacts with others, he or she may show avoidant behavior in smaller ways that have been labeled as safety behaviors. The client’s dysfunctions were also being held strongly by the two types of conditioning. His incident of performing in front of a room full of senior authority figures, his nervousness and the biased focusing on negative comments given by his boss, made the situations fearful for him so he developed performance anxiety. He started to link further performances with that one incident and believed that the same would occur in all situations and he will be negatively evaluated by all. Because of this, the client was unable to perform in future situations as well.

Cognitive theorists explain SAD in the terms of dysfunctional cognitions and maladaptive thinking patterns. They propose that people with this disorder hold a group of social beliefs and expectations that consistently work against them. Among the beliefs are, ‘I won’t be able to perform adequately’, ‘I must give a 100%’, ‘There is no chance of any mistake’, ‘People may think less off me’. Cognitive theorists hold that, because of these beliefs, people with social anxiety disorder keep anticipating that social disasters will occur, and they repeatedly perform “avoidance” and “safety” behaviors to help prevent or reduce such disasters. The client also presented with the same beliefs. He held unrealistically high social standards and expected himself to perform perfectly in social situations, even though he had never been so vocal or good with expressing himself. Moreover, his negative anticipation and low confidence in himself triggered a self-fulfilling prophecy making it difficult for him to perform in social situations.

Case Conceptualization (Clark & Wells, 1995)

Management Plan

The management plan was devised specific to each symptom on the lines of Cognitive Behavior Therapy.

Short-Term Goals

Short Term Goals	Therapeutic Intervention
To develop therapeutic alliance with the client	Collaborative empiricism, empathy, active listening, unconditional positive regard
To educate client about his illness, symptoms, development and maintaining factors	Psycho-education Normalization Socialization with the CBT model Productive and unproductive worry
Challenging faulty beliefs and generating alternatives	Cognitive restructuring (Triple column) Cost-benefit analysis of thoughts
Practicing social situations and decreasing avoidance/ safety behaviors	Systematic Desensitization Coping Statements
Eliminating physiological symptoms	Progressive Muscle Relaxation
To improve communication and confidence	Assertiveness Training (Role-Playing)
Relapse Prevention	Therapy Blueprint

Long-Term Goals

Continuation of short term goals
Follow-up sessions
Social Skills Training

Session Reports/Management Plan

Session No.1 Time of session: 45 minutes

Session Agenda

Develop therapeutic alliance, History taking, Mental Status Examination, Symptom elicitation and subjective ratings

Techniques

History taking

Rationale: To obtain a comprehensive account of the development of client’s problems, its predisposing, maintaining and precipitating factors. Procedure: Information about the client’s symptoms, their intensity and presenting situations were elicited. Moreover, client’s support system, social functioning, familial life and personal views were also obtained in the history Outcome: The client elaborately discussed all his life domains and cooperated with the client in giving every piece of information.

Mental Status Examination

Rationale: To assess the client’s current level of functioning (cognitive, behavioral, affective and general appearance). Procedure: The therapist observed several of the areas herself such as grooming, eye contact, posture, gait, speech etc. While some questions were directly asked from the client i.e. questions about cognitive functioning, mood, insight etc. Outcome: The significant information obtained through MSE was the anxious and irritable mood of the client, less eye contact while talking, shaky voice and fidgeting while talking.

Symptoms Elicitation and Subjective Rating

Rationale: To understand the client’s problems, elicit disorder specific symptoms and obtain a subjective rating of each symptom. Procedure: The client was asked to tell about the symptoms she experienced while the therapist tracked down the relevant and specific details. Moreover, the client rated her symptoms on a scale of 0-10. Outcome: The procedure helped in identifying the specific severity of each symptom and helped in prioritizing them for treatment.

Therapeutic Alliance

Rationale: To maximize the feeling of comfort and straightforwardness between the therapist and the client. Procedure: It was established through emotional reciprocity which included the therapist’s active listening and responding with appropriate non-verbal communication. The therapist also paraphrased repeatedly during the session to ensure clarity of client’s description and make him certain that he was being understood. The client was also given empathy and unconditional positive regard which was practiced by having a non-judgmental attitude during the session and understanding the client’s problems from his point of view. Any verbal or non-verbal of downsizing the issues or considering them less important were avoided. Outcome: The strong therapeutic alliance developed in the initial sessions led to effectiveness of therapy. Rapport was effectively developed with the client it kept the client motivated for treatment throughout the therapeutic process for procedures like homework assignments and other behavioral strategies.

Session No.2 Time of session: 45 minutes

Session Agenda

History taking (continued), Differential diagnoses, formal assessment (Liebowitz Social Anxiety Scale)

Review of previous session: The history obtained in the first session was reviewed to continue in the current session.

Techniques

History taking (continued)

Rationale: To probe more information about the client’s past life and obtain data which was previously unable to get. Procedure: The client was asked about his symptoms in more detail and about the situations in which he previously felt the same way. His incident of the performing in the presentation was discussed in depth. Outcome: The review of history helped in obtaining more information that would aid in treatment.

Differential Diagnoses (American Psychological Association, 2013)

Rationale: To obtain a distinct analysis of the diagnoses and rule out implausible ones. Procedure: The diagnosis for Social Anxiety Disorder was probed more while symptoms of Generalized Anxiety Disorder, Social Phobia and Normal shyness were ruled out. Outcome: It helped in confirming the client’s diagnosis of Social Anxiety Disorder.

Formal assessment (Liebowitz Social Anxiety Scale, 1987)

Rationale: To obtain more information about the client’s problems by using standardized and developed tools. Procedure: The client was given a questionnaire during the session. He was explicitly given the instructions needed to complete the test. Items and their options were explained. He was given ample time to complete the questionnaire with ease. Outcome: He scored high in experiencing anxiety in social situations and experienced significant performance anxiety in those settings.

Homework given: Dysfunctional thought record was given for the client to fill.

Session No.3 Time of session: 45 minutes

Session Agenda

Psycho-education and normalization, socialization, productive and non-productive worry.

Homework review: The DTR filled by the client was reviewed which helped in identifying the situations in which the client felt anxious, thoughts that occupied his mind and his reactions towards those situations.

Techniques

Psycho-education and Normalization (Wells, 1997)

Rationale: To educate the client regarding his diagnosis, their causes, development, treatment options etc. Procedure: The client was educated regarding his illness, the triggering and maintaining factor and the fact that his symptoms were experienced by many other individuals. It helped the client in reviewing himself as part of a bigger community rather than being alone in the specific set of symptoms. While discussing about the prognosis of the client, he was told about collaborative empiricism and how therapy was to be conducted. He was educated about his active role in setting the agenda of therapy, setting short-term and long-term goals, his compliance with homework assignments and active communication with the therapist. Outcome: Normalizing the disorder proved comforting and effective for the client. The technique also proved to be beneficial for him to solve his queries.

Socialization (Wells, 1997)

Rationale: To make the client aware of the development and process of his symptoms. Procedure: The triggering factors in the model such as the particular social situation, assumptions that are activated and consequent behaviors were exemplified with the client to make the symptoms and their formation more explicit. Outcome: The client agreed with the CBT model and understood where intervention was to take place. He helped in identifying more examples from his life as well.

Productive and non-productive worry

Rationale: To make the client know the difference between the benefits and disadvantages of worry. Procedure: A productive worry is a concern about something that is plausible whereas unproductive worry is about useless things or things that have a little chance of happening (Leahy, 2003). He was explained how anticipating worry about events that have a low probability of happening and for which one has the least evidence can make the individual trapped into an unproductive cycle. The cycle does not lead to a solution rather just utilizes the person’s energy making him more tensed, helpless and lethargic. Outcome: He understood the difference between worrying and how he was stressing himself by unproductive worry.

Homework: Psycho-educational material was given to the client to review at home as well.

Session No.4 Time of session: 45 minutes

Session Agenda

Cognitive restructuring (Double-column), Cost-benefit analysis of thoughts

Review of previous session: Psycho-education and productive and non-productive was briefly reviewed to freshen the client’s understanding.

Techniques

Cognitive restructuring (Double-column) (Wells, 1997)

Rationale: To make the client identify his cognitive errors Procedure: The client’s dysfunctional thought record was kept in consideration after which thoughts were emphasized. He was briefed about the different cognitive distortions which an individual makes while thinking. Each mistake in thinking was explained with various examples after which the client was asked to identify his own distortions. A double column was made in which the client wrote down his irrational thoughts and identified the distortion by writing it down in front of the thought. Outcome: The client was able to identify mistakes in his thinking which made him realize the role cognitions played in exacerbating his symptoms.

Cost-benefit analysis of thoughts (Wells, 1997)

Rationale: To make the client understand the damage done by maladapative thoughts and confidence gained by positive and adaptive thoughts. Procedure: He was asked to list down the advantages and disadvantages of a maladaptive thought. After the identification, he was given an opposite positive thought and list down the benefits and disadvantages of that particular thought. The client wrote down all the pros and cons which came to his mind. Outcome: The disadvantages of maladaptive thought were more while the benefits of adaptive thought was significant hence indicating to the client that thought was proving to be destructive rather than the situation itself.

Homework given: The bibliotherapy of cognitive distortions was given to the client to take it along with him and identify more distortions in his thinking until the next session.

Session No.5 Time of session: 45 minutes

Session Agenda

Cognitive Restructuring (Triple column), Systematic desensitization, Relaxation exercise.

Review of previous session: The client was asked about the confusions he may have regarding the last session. Cognitive distortions were briefly explained again so that restricting may be continued in the present session as well.

Homework review: He was asked if he was able to identify his maladaptive thoughts and mistakes in thinking. He reported that he sometimes became conscious of his negative automatic thoughts and also tried to identify the errors in his thinking.

Techniques

Cognitive Restructuring (Triple column) (Wells, 1997)

Rationale: To make the client change his maladaptive thoughts into adaptive ones by eliminating cognitive errors. Procedure: The client’s already filled double column was now increased by putting a third column. He was explained about the double standards he was keeping for himself and how his perfectionism was causing him to perform poorly. He was then probed to write down more realistic, rational and adaptive thoughts in the third column which would ultimately help in subsiding his symptoms and realistically help in improving his performance. Outcome: He was able to do the required task easily but had to be constantly recommended to bring the adaptive thoughts into his repertoire rather than just writing them down.

Systematic desensitization (Introduction)

Rationale: To reduce the client’s avoidance behaviors by exposing him to anxiety provoking situations and coping with them. Procedure: The client was briefed about the process of this technique. He was told about the tasks he would be required to do and how he will cope with the situation. Outcome: The client was hesitant in continuing with the procedure but he was convinced with repetitive explanations about how he will benefit from the technique at the end.

Homework given: To continue triple column at home as well and practice to bring rational thoughts in the repertoire.

Session No.6 Time of session: 45 minutes

Session Agenda

Relaxation exercises, formation of hierarchy and conduction of first step of Systematic Desensitization.

Review of previous session: The last session was reviewed to freshen the client’s understanding of the process of systematic desensitization so that it could be continued in the current session as well.

Techniques

Relaxation Exercises

Rationale: To teach the client how to cope with the stressful situations. Procedure: The client was taught progressive muscle relaxation to know the difference between the tensed and relaxed muscles. 16 muscles of the body were focused and altered in making them tensed and relaxed. Outcome: The client understood the exercise well and it helped in relaxing the client’s tensed muscles during stressful times.

Formation of hierarchy and Conduction of first step of the hierarchy (Miltenberger, 1997)

Rationale: To expose the client towards an anxiety provoking situation and try to cope with it. Procedure: The client was first helped in forming a hierarchy in which situations were listed down. The situations were specific in which the client felt anxious. A list was made which incorporated all situations and systematic units of distress were written down against each situation. The list was made in an ascending order depending on the SUDs. The first step in the ladder was to make the client talk to an unknown girl for 10-15 minutes. He was asked to sit in a room where a girl unknown to the client was brought inside. He was briefed before the meeting that he will have to talk to the girl about himself. The therapist constantly monitored the session. The client became confused during the time the girl sat there but eventually discussed his likes and dislikes and general information with her. He had to be prompted 2-3 times. After the meeting, the client was given feedback by the girl he talked to and by the therapist. He was told about his performance and the presence of any symptoms that he had assumed for himself. Outcome: The client was convinced that no one noticed his face flushing or sweating rather were more interested in his answers. He himself made assumptions and got worried upon them. The procedure was repeated again with another girl the therapist knew but the client didn’t.

Homework given: The client was asked to practice relaxation exercises twice a day and also expose himself to a situation where he had to talk to a female colleague. He was told to practice the techniques of cognitive restructuring and deep breathing to cope with the situation.

Session No.7 Time of session: 1 hour

Session Agenda

Continuation of Systematic desensitization and introduction to mindfulness

Review of previous session: The client was asked about his views regarding the last session and how it helped him. The client gave his own feedback about the things he should have done or said in the two meetings with unknown girls and how he could have improved his performance.

Homework review: The client practiced the relaxation exercises which soothed down his body. Moreover he also attempted to talk to his female colleague. He was able to do it for 5 minutes even though he was anxious. He controlled himself by revising the rational thoughts in his mind.

Techniques

Continuation of Systematic desensitization

Rationale: To expose the client to more anxiety-provoking situations and habituate the client ot relax himself. Procedure: 3 more steps of the hierarchy were carried out in this session. Talking on the phone in front of strangers, eating in public and talking to 3 unknown people were the tasks carried out by the client. The client was given ample time to stay in the situation and then relax himself by giving positive self-instructions and changing his cognitions. Moreover he also relaxed himself by using deep breathing. Outcome: The client was able to perform all the tasks but with hesitation because of which the tasks were again given as homework to practice at home.

Homework given: The client was asked to practice the hierarchy steps again at home along with the next two steps of the ladder. He was also asked to try to remain in the present in stressful situations according to the principles of mindfulness.

Session No.8 Time of session: 1 hour 15 minutes

Session Agenda

Systematic desensitization continued, therapy blueprint, post-assessment.

Homework review: He was asked about the hierarchy steps which were to be carried out at home. The client was successful in handling the situations without avoiding them. He had to go through them repeatedly to improve his performance.

Techniques

Continuation of systematic desensitization

Rationale: To expose the client to the most anxiety producing situation for him. Procedure: The client was asked to come prepared for a 10-slide presentation on his work which he will give to a group of people. The client gave the presentation to 4 unknown people after which feedback was given to him. His assumptions regarding his anxiety symptoms and his performance were discussed in the feedback. Outcome: The client was able to give the performance but with extreme sweating and anxiousness. For this purpose he was recommended to practice and go through this task again and again to get habituated and practice rational thoughts.

Therapy Blueprint

Rationale: To revise all the techniques done in previous sessions and provide a toolbox for the client to use to tackle with his symptoms in the future. Procedure: As the client had to leave early all techniques especially cognitive restricting and systematic desensitization were discussed. Moreover emphasis on positive self-instructions and practice of each technique was emphasized. Outcome: He understood the importance of each technique and decided when to employ which strategy. His confusions regarding the process were clarified.

Post-assessment

Rationale: To assess the difference in symptoms of the client from pre assessment. Procedure: The client was asked to rate his symptoms again on a scale of 0-10. He was also asked to attempt the Liebowitz Social Anxiety Scale again. Outcome: There was a significant difference between the pre and post assessment ratings of the client.

Visual Analogue

Table 7: Symptoms and their severity according to the client

Symptoms	Pre-treatment Severity (0-10)	Post-treatment Severity (0-10)
Feeling of embarrassment while going in front of people	9	5
Fear of scrutiny, evaluated or being ashamed	9	4
Fear of performing inadequately	9	2
Becoming confused in front of others	9	4
Not being able to give correct answers or respond appropriately in front of seniors	8	3
Avoiding presentation or social activities	8	1
Sweating, flushing of face	8	3

Liebowitz Social Anxiety Scale

Table 8: Area and client’s scores on the Liebowitz Social Anxiety Scale

Area	Pre-treatment scores	Post-treatment scores
Performance Anxiety subscale	53	15
Social situation subscale	15	5
Total Score	68	20

Outcome of therapy

The pre and post assessment of the client shows that the therapy was efficacious and there was betterment in the client’s symptoms. The client was now able to function better in his life and experience les anxiety in social situations.

Limitations and suggestions

Therapy had to be terminated after 8 sessions as the client had to complete a course in another city. He could not take the sessions further hence he was advised to seek treatment at his new place or come for a follow-up session after his course was over.

References;

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author
Liebowitz, M. R. (1987). Social Phobia. Mod Probl Pharmacopsychiatry 22:141-173
McCabe, R. E., Antony, M. M., Summerfeldt, L. J., Liss, A., & Swinson, R. P. (2003). Preliminary examination of the relationship between anxiety disorders in adults and self-reported history of teasing or bullying experiences. Cognitive Behaviour Therapy, 32(4), 187-193.
Miltenberger, R. G. (1997). Behavior modification: Principles and procedures. United States of America: Brooks/Cole Publishing Company
Ollendick, T. H., & Hirshfeld-Becker, D. R. (2002). The developmental psychopathology of social anxiety disorder. Biological Psychiatry, 51(1), 44-58.
Wells, A. & Clark, D.M. (1997). Social phobia: A cognitive approach. Chichester: Wiley.